ClinkShrink: Run for the Hills!

In Treatment is back. Starts tonight. Stay tuned.

What I Learned: Part 3

Continued coverage of the American Academy of Psychiatry and Law (AAPL) conference. For Part 2, click here.

The first talk of the day was a discussion of SB1070, the Arizona law which required police officers to verify the citizenship status of anyone suspected of being an illegal alien. I learned that there were several parts to the law and that some parts were under injunction and were working their way through legal challenges. An immigration attorney talked about the ambiguity of the law and how it could be misapplied. For example, one provision barred anyone from picking up day laborers. In theory, it could be used against emergency medical personnel who transported illegal aliens. He also talked about the problems faced by mentally ill illegals who were deported to Mexico where they had no family support or access to mental health services.

I was planning to go the session about fMRI's in court, but I ended up getting invited on a trip to Tupac, AZ. Very cool little place with nice shops. Incidentally, Tupac is just past the Titan Missile Museum. I didn't go tour the museum because it creeped me out a bit but you can see a short video of the place on their web site.

I got back for the afternoon sessions. Dr. Ezra Griffith gave the Isaac Ray lecture entitled "Identity, Representation, and Oral Performance in Forensic Psychiary." I could never give it justice in a short summary. Fortunately you can read the full text of his talk here, because AAPL continues to be one of the few organizations that still keeps it's articles open to the public for free. Griffith talked about the role of perfomance in expert testimony. While most people would think of this solely in terms of communication skills, he put testimony in the context of the performing arts or literary narrative. The telling of the crime "story" is like drama, with behavioral elements and a physical context (the court room). The expert's purpose is to develop the facts as one would a character, so that the listener can hear the facts in a coherent way and is able to infer a line of understanding about the case. The jury then chooses between two competing narratives, the defense and the prosecution. Read the paper, Ezra explains it much better than I can.

The last session was about privacy in forensic psychiatry. I tweeted the highlights until my data coverage gave out. There was a lot of discussion about the "evils" of social media and the Internet, and how it could be used against you. There was no mention of any potential utility of Facebook, Twitter, blogs, etc. which I found highly ironic. Here I am using these same tools to (hopefully) provide a little public education while the speaker was cautioning the audience against them. The second speaker gave a great presentation about patient privacy rights in the emergency department. He presented literature that psychiatric patients get disrobed and searched in the emergency department twice as often as medical patients, although both patients are equally likely to bring weapons into the department (about 14% of all ED patients are found with weapons). Finally, there was an interesting talk about DNA privacy, legal cases challenging mandated DNA sampling (eg. sex offenders and violent offenders) and potential future misuse of current DNA samples. There have been two recent lawsuits challenging how hospitals store and use newborn blood samples drawn for routine disease screening. Read the details here.

So that's the end of day three. There is one more morning session tomorrow, but I may or may not have time to blog afterward. Hope you enjoyed this.

PS The support duck did not go to Tupac.

What I Learned: Part 2

Continued coverage of the American Academy of Psychiatry and Law (AAPL) conference. For Part 1, click here.

Day Two began with a section on PTSD as a criminal defense in military criminal cases. There was a presentation of a murder case committed by several military personnel in Iraq, followed by a discussion of the uniform code of military justice (UCMJ) rules of criminal procedure. The limitations of PTSD as a diagnosis was discussed, specifically the fact that many symptoms of PTSD overlap with other psychiatric diagnoses and that some people meet symptom criteria for PTSD without ever being exposed to a traumatic event. In 2008, 2.9 million veterans were receiving compensation for PTSD.

In criminal cases, defendants can claim self-defense if they have a reasonable belief that they are in imminent danger of serious bodily injury or death, if the force used in self-defense was reasonable, if the defendant was not the aggressor and if the defendant had no opportunity to retreat. Problems happen when the defendant reasonably believes he is in danger, but there is no objective evidence of imminence. (Eg. battered spouse syndrome and "burning bed" cases: a woman believes she is in danger and pre-meditates violence in self defense.) Soldiers with exposure to traumatic events may base a PTSD defense on a reasonable belief of danger, in the absence of imminence. Although the term "battered soldier syndrome" is not actually used in these military cases, they are clearly drawing an analogy.

As an aside, the UCMJ is interesting in that in courts martial, the military panel (analagous to a jury) decides guilt and also passes sentence. Judges have no role in sentencing. Also, there is no option for bail at the pretrial stage. Defendants have a right to a trial within 120 days, which is not much time to prepare a case for a felony offense.

In a presentation about zolpidem (Ambien) I learned that there were 22 criminal cases at the appellate level in which this medication was used as a defense. Ten were driving cases, seven were violent offenses. Zolpidem has been associated with sleep disordered behavior when combined with an SSRI. There have been 16 cases reports of zolpidem causing improvement in a chronic vegetative state.

There was a fascinating talk about tasers given by a guy from Utah. Apparently tasers have a USB data port that is used to gather stored information about when the taser was used and how many tasing cycles were triggered on a defendant. The presenter collected data from many police departments around the country regarding taser use and the nature of the defendant. He found out that in two-thirds of the cases the taser is never actually fired---merely pointing the taser at a defendant is enough to cause the defendant to surrender. When a taser is used, 82.2% of people required a single cycle. The majority of the cases in which a taser was used was on a defendant who was mentally ill and/or intoxicated. According to 1999 Justice Department data, only 2.1% of arrests actually require the use of a police weapon.

I went to the forensic sciences lecture, which is usually my favorite presentation. The American Academy of Forensic Sciences is a companion organization to AAPL and some of our members are shared between the two organizations. Anyway, this year's presentation was about computer crime. Sadly, it was bad. While the investigator was a good speaker, he didn't say much of anything about the techniques of how computer crime is actually investigated. There was no case presentation. The only crime discussed was online child pornography. The mental health professional talked about child porn users, but made at least three pretty outrageous anti-feminist statements. (Eg. women who made late accusations of child sexual abuse had been 'brainwashed by the feminist movement.') A female forensic healthy audibly blurted out "that's bullshit!" and I could hear the silent dropping of jaws. The most enjoyable part of this talk was when the computer investigator had trouble getting the audience survey system to work.

Lastly, I went to a talk about a survey given to 492 members of the South Carolina bar. 83% of the lawyers said they felt their law school training about mental health law was inadequate. Two-thirds had personal or close experience with mental illness. Judges were the least knowledgable about mental health law compared to public defenders, private attorneys and prosecutors.

Tidbits from the poster session:

• 27 states have statutes with lifetime restrictions on gun ownership for people with mental illness. Other states have time limited restrictions on ownership, and some allow restoration of full rights contingent on a physician's documentation of recovery.
• One poster studied inpatient threats in a state hospital over one year. Only one-quarter of the threats were deemed credible by the treatment team, and only one-half of these threats were thought to meet criteria to carry out a Tarasoff warning.
• There was an interesting review of the Maurice Clemmons case in which public information was used to assess his risk of violence. I blogged about the case here, and provided links to the published clemency materials. Using two violence risk assessment instruments, the poster found Clemmons to be a high risk offender. Easy to say based on his history, but of course the limitation of static risk assessment instruments is that your base risk never lowers. You can get worse, but never better.
• A national household survey of substance abuse, done annually with tens of thousands of people, showed that 3.8% off all women had used methamphetamine at least twice in the past year. Female meth users were more likely than users of other substances to be involved with the law, but not necessarily for violent offenses.
• Two states automatically drop misdemeanor charges against incompetent defendants, as required by their statutes.
• One study found no correlation between a history of childhood sexual abuse and being a perpetrator or victim of inpatient violence.
• Prisoners over the age of 65 are twice as likely to have at least one chronic medical condition compared to an age-matched sample in free society.
• Medical students from UCSD who rotate in a jail for their psychiatry experience consistently rate this rotation as their favorite. One quote from the medical student survey stated: "I love jail!"

Finally, my favorite poster: THE FORENSIC ASPECTS OF SERVICE ANIMALS!

YES!!! EMOTIONAL SUPPORT DUCKS HAVE COME TO AAPL!

This is the poster that won my heart. We've discussed this on the blog and we mention it in the book. Now, the "official" word. A poster entitled "Noah's Ark: A Forensic Review of Service Animals in Psychiatric Settings" provided an overview of ADA requirements for service animals in hospitals and clinics. In addition to guide dogs for the blind, other service animal cases involved monkeys, chimpanzees, miniature horses and parrots. Animals may be excluded from operating rooms but not any other general treatment setting. Potential for infection cannot be used to exclude animals, nor can mere concern about safety separate from an actual safety-related incident. Animals have to be able to meet minimal expectations for cleanliness, orderliness, nonaggression and "unnecessary vocalization". The sole determinant of whether an animal is a service animal versus a pet is the patient's declaration: a health care facility cannot demand documentation that an animal is certified or trained as a service animal. Finally, there have been cases of fraudulent service animals: people who put homemade "vests" on their animals and falsely identified them as a service animal. In California this is a crime punishable by six months of incarceration and a thousand dollar fine. I'm not sure how you'd get a vest on a fake service parrot.

So there you have it. I'm bringing my duck to the next session.

What I Learned: Part 1

For new readers, it's my tradition to put up posts summarizing tidbits I picked up at the annual American Academy of Psychiatry and Law (AAPL) conference. It's random, it's not explained in detail, but it's stuff I thought was interesting.

The conference started out with a keynote speech by AAPL President Stephen Billick. The title of his talk was "Be True To Psychiatry". His point was that forensic healthys are clinicians first, and that even a forensic evaluation can have therapeutic effects. He cited many examples in his practice in which a criminal or civil evaluation had potential beneficial "side effects" regardless of the forensic opinion. His main point: the forensic healthy's obligation to be neutral and objective does not preclude kindness. A point well taken, and appreciated.

A session on suicide risk assessment gave a very nice illustration of the basic problem inherent in these assessments: even assuming an "ideal" case situation with a "perfect" healthy, a thorough suicide risk assessment would take four hours. Risk assessment is time consuming and inherently will be incomplete. We make the best decisions we can based on the limited data we have at the time. A malpractice defense attorney talked about inpatient suicides: he was shocked when he realized in the course of his practice that many doctors didn't know that most inpatient deaths occured by hanging. They do. About 1500 deaths per year, in fact. Seventy percent of suicide deaths take place in the patient's bedroom, bathroom or closet. One-third happen while the patient is on fifteen minute checks.

There were a few themes to today's conference: conflicts of interest, maintenance of certification, and neuroimaging. The luncheon speaker was the best one I've ever heard at an AAPL conference. Dr. Helen Mayberg has been doing neuroimaging studies for 25 years and was one of the creators of deep brain stimulation. She has testified in several death penalty cases regarding the limitations of inference in imaging, particularly in regard to forensic issues. She was balanced, impartial and scientifically impeccable. Notable quote: "Brain scans have no place in the court room." An afternoon session on "diffusion tensor imaging" and mild traumatic brain injury basically came to the same conclusion, albeit after an astoundingly incomprehensible explanation of "diffusion tensor imaging" technology.

There was a great overview of Munchausen's syndrome by proxy, including a summary of 38 family case studies in which a mother was convicted of MSBP. In this case series a third of the mother's had some health care training and 60% had previously had factitious disorder themselves. Ninety percent of the perpetrators did not admit their abuse even after conviction. Several factors were associated with a worse outcome for the child: reunification with the untreated mother, an absent father, and a history of MSBP abuse lasting over two years. If the child was abused by suffocation or poisoning, about a tenth of them eventually died two years after reunification. Siblings in these cases were also at significant risk of being victims of MSBP.

Another session I attended was a 15 year review of state and Federal case law regarding automatism defenses. An automatism defense is one in which the defendant alleges that a crime was due to some unconscious behavior, like sleepwalking or seizure. Without going into legalisms, I'll just say that states are divided on whether or not automatism is allowed as the basis of an insanity defense. It's clinically and legally complicated so I leave the details for a future blog post if I have the inclination to go into it. If you can't wait, there's a nice concise description here.

Finally, some interesting tidbits from the poster session:

• There were two posters on forced meds for prisoners. One poster found a significant decrease in infractions and disciplinary problems for prisoners who were ordered to take meds against their will. Another poster found split results: some had fewer infractions, some had more. Infractions may be related to mental illness, but others are due to personality problems and involuntary meds may not touch this.
• States are developing jail diversion programs for veterans, modeled after diversion programs for the mentally ill.
• A study of suicides in New York's prison and jail system showed that 2/3rd's of completed suicides had no previous history of suicide attempts.
• Dr. Paul Federoff and his colleagues had an interesting poster in which they found that increased LH and FSH levels correlated with violent and sexual recidivism. He had another poster session which described a nonprofit program that helped sex offenders transition back into the community. I'm always impressed by the quality of Canadian forensic research.
• There are 5000 honors killings per year worldwide, and most are committed by fathers or brothers.
• Mental health providers are not required to report threats against the President except for threats covered by state Tarasoff statutes.
• Parasomnias sometimes result in violence, but this is rare. Most violence is from random thrashing movements, although there have been rare incidents of parasomnia-associated choking.

So that's it for today. Tomorrow's topics: murder in Iraq, AAPL interfacing with the American Medical Association and the American Psychiatric Association, the forensic sciences sampler (my favorite!! This year the topic is computer crime), and the "Zolpidem defense".

I'll be tweeting throughout the conference. The preliminary program is available here, and I'll consider requests about which sessions to attend.

Funny: At the Expense of Whom? Please vote

There's this funny thing about humor: it's not funny to everyone. I tend to like the unexpected, what's dry or witty or sarcastic. ClinkShrink, bless her Midwestern soul, likes puns. And Roy, well he still likes potty humor.

Jokes are often made at the expense of a group, and I don't understand a lot of ethnic, racial, put-down humor. That said, the other day I went to put up a post, and since I've recently written about how to find a healthy, and what makes mental illness bad---both serious posts that took me a while---I thought I'd opt out and just went to youtube and searched for "psychiatry humor." Lazy, you say. Yup! But I listened to the audio of Psychiatry Hotline and I laughed out loud. Even though I hesitated for a moment, I posted it.

Two readers and Roy pointed out that this YouTube makes fun of people with mental illnesses. Does it? I had trouble seeing this as the same phenomena as your usual make-fun-of-a-group in a hurtful way type joke. For one thing, the "if you're a nymphomanic press...." was the part I laughed out loud at, and nymphomania is not a psychiatric diagnosis. Hypersexuality is a symptom of some disorders, but if I can't laugh at a nymphomania joke, maybe I should go home and learn to like bad puns. If you're co-dependent, have someone help you press 5. Ah, co-dependence is not a psychiatric diagnosis either, but a lay designation used to describe a constellation of behaviors in a way that some people find to be meaningful and helpful. The rest of the tape....okay, I admit, it pokes fun of people with illnesses. Somehow, I couldn't come to terms with this as being bad. I still own a Prozac mug and my friends comment when I serve them coffee in it---- is that bad? It certainly gets more of a reaction than a Lamisil mug would get.

Here is the thing though, something invaluable that I learned from Dr. Fox who taught us family therapy behind a one-way mirror : Insults and offenses are defined by those who are insulted or offended. If someone is injured, that's what counts and the offending party is left to recant. The reality isn't in "Oh, but you should find this funny" or "It's not offensive." The reality is that someone is offended and those feelings are valid. With that, I should take the post down. However-- and do forgive me, Dr. Fox--but it is hard to negotiate life (much less a blog with a duck mascot) if one tiptoes through afraid of insulting or offending any one of the 2,500 weekly unique visitors.

So I'm taking a vote. And I want to know if YOU are offended personally, not if this is potentially offensive to someone somewhere.

Here's the link if you want to listen again:

http://healthyandmedic.blogspot.com/2010/10/its-okay-to-laugh-at-jokes-your-career.html

And here's the ballot:

I Met a Guy With No Arms and He Plays Piano ....Really

I FELT SORRY BECAUSE I HAD NO SHOES TILL I MET A MAN WITH NO FEET THAN I MET A MAN WITH NO ARMS AND HE PLAYS PIANO...REALLY

Chinese Man Electrical Accident Amputee Plays Piano by Foot

You have to believe to achieve. Many things that we think are impossible almost unimaginable can be done but you have to believe... Here is something I would have a hard time believing if I hadn't seen it...This Man had lost both arms as the result of an electrical accident when he was a child. Yet here he is on this video from China's Got Talent playing piano well! (certainly better than me)..Click on the video to start.

Pull & Pray - zDoggMD's Safe Sex Song

ZDoggMD's rapping video about safe sex is a beautiful example of how to grab the attention of your target audience using a medium and tone that they can get down with.

While you are on ZDogg's site, check out their first News Per Rectum podcast, Potty Mouth (punchline: "I gave a crap today"), about fecal transplants for pre-diabetes. Coincidentally, our first podcast also had the word "potty" in it (Podcasting Makes You Potty).

So, I gotta say... these guys are hilarious. Educational (sometimes marginally so) while being thoroughly entertaining and mildly offensive. Their production value is quite good, as well.

That being said, I don't expect us to follow in their vlogging footsteps.  But keep an eye on these guys.